A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take?

Decrease maintenance IV solution infusion rate.

Place the client in a lateral position.

Administer oxygen via face mask at 2 L/min.

Administer misoprostol 25 mcg vaginally.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Decreasing the maintenance IV solution infusion rate is not the appropriate action for addressing late decelerations of the fetal heart rate. Late decelerations are a concerning sign during labor, indicating possible fetal distress. This can be caused by inadequate oxygenation of the fetus, and reducing IV fluids would not directly address this issue.

Choice B rationale:

Placing the client in a lateral (side-lying) position is the correct action when late decelerations are observed. This position helps to improve uteroplacental blood flow and can relieve pressure on the inferior vena cava, thus increasing oxygen supply to the fetus.

Choice C rationale:

Administering oxygen via face mask at 2 L/min is not the priority action in response to late decelerations. While oxygen may be beneficial in certain situations, it is not the initial intervention for addressing fetal heart rate decelerations.

Choice D rationale:

Administering misoprostol 25 mcg vaginally is not appropriate for addressing late decelerations. Misoprostol is a medication used for cervical ripening and induction of labor, but it does not directly address fetal heart rate changes.

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Correct Answer is D

Explanation

Choice A rationale:
Bright, red vaginal discharge is not a typical manifestation of an ectopic pregnancy. Instead, it can be indicative of other conditions such as miscarriage or vaginal bleeding.

Choice B rationale:
A scaphoid abdomen is not a typical manifestation of an ectopic pregnancy. A scaphoid abdomen is seen in cases of diaphragmatic hernia, where the abdominal organs move into the chest cavity, leaving the abdomen with a sunken appearance.

Choice C rationale:
Elevated blood pressure is not a typical manifestation of an ectopic pregnancy. High blood pressure can be associated with conditions like preeclampsia but is not specifically linked to ectopic pregnancies.

Choice D rationale:
Sharp pelvic pain is a common manifestation of an ectopic pregnancy. As the fertilized egg implants outside the uterus, often in the fallopian tube, it can cause pain and discomfort.

A. Abdominal distention. B. Petechiae. C. Increased muscle tone. D. Jitteriness.

Correct Answer is D

Explanation

Choice A rationale:

Abdominal distention is not a typical manifestation of hypoglycemia in a newborn. Instead, it can be associated with gastrointestinal issues or other conditions affecting the abdominal organs.

Choice B rationale:

Petechiae are small, pinpoint purple or red spots that appear on the skin due to broken capillaries. They are not related to hypoglycemia and can be caused by various factors such as blood clotting disorders or infections.

Choice C rationale:

Increased muscle tone is not typically associated with hypoglycemia in a newborn. Instead, hypoglycemic babies may exhibit decreased muscle tone, lethargy, and poor feeding.

Choice D rationale:

Jitteriness is a common manifestation of hypoglycemia in newborns. It is characterized by rhythmic tremors, often involving the face and extremities. This occurs because the brain relies heavily on glucose for energy, and low blood sugar levels can affect neurological function, leading to jitteriness. Prompt intervention is necessary to prevent further complications.

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A nurse is caring for a client who is receiving oxytocin for induction of labor and notes late decelerations of the fetal heart rate on the monitor tracing. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is at 8 weeks of gestation and has an ectopic pregnancy. Which of the following manifestations should the nurse expect?

Correct Answer is D

Explanation

A nurse is assessing a newborn whose mother had gestational diabetes mellitus. The nurse should monitor for which of the following findings as a manifestation of hypoglycemia?

Correct Answer is D

Explanation

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